title: Integration and task shifting for TB/HIV care and treatment in highly resource-scarce settings: one size may not fit all.
abstract: BACKGROUND
  A crucial question in managing HIV-infected patients with tuberculosis (TB) concerns when and how to initiate antiretroviral therapy (ART). The effectiveness of CD4-stratified ART initiation in a nurse-centered, integrated TB/HIV program at primary care in Kinshasa, Democratic Republic of Congo, was assessed.
  
  
  METHODS
  Prospective cohort study was conducted to assess the effect of CD4-stratified ART initiation by primary care nurses (513 TB patients, August 2007 to November 2009). ART was to be initiated at 1 month of TB treatment if CD4 count is <100 cells per cubic millimeter, at 2 months if CD4 count is 100-350 cells per cubic millimeter, and at the end of TB treatment after CD4 count reassessment if CD4 count is >350 cells per cubic millimeter. ART uptake and mortality were compared with a historical prospective cohort of 373 HIV-infected TB patients referred for ART to a centralized facility and 3577 HIV-negative TB patients (January 2006 to May 2007).
  
  
  RESULTS
  ART uptake increased (17%-69%, P < 0.0001) and mortality during TB treatment decreased (20.1% vs 9.8%, P < 0.0003) after decentralized, nurse-initiated, CD4-stratified ART. Mortality among TB patients with CD4 count >100 cells per cubic millimeter was similar to that of HIV-negative TB patients (5.6% vs 6.3%, P = 0.65), but mortality among those with CD4 count <100 cells per cubic millimeter remained high (18.8%).
  
  
  CONCLUSIONS
  Nurse-centered, CD4-stratified ART initiation at primary care level was effective in increasing timely ART uptake and reducing mortality among TB patients but may not be adequate to prevent mortality among those presenting with severe immunosuppression. Further research is needed to determine the optimal management at primary care level of TB patients with CD4 counts <100 cells per cubic millimeter.
authors.affiliation: *Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; and †School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo.
authors.forename: Annelies
authors.initials: A
authors.lastname: Van Rie
authors.forename: Monita R
authors.initials: MR
authors.lastname: Patel
authors.forename: Mbonze
authors.initials: M
authors.lastname: Nana
authors.forename: Koen
authors.initials: K
authors.lastname: Vanden Driessche
authors.forename: Martine
authors.initials: M
authors.lastname: Tabala
authors.forename: Marcel
authors.initials: M
authors.lastname: Yotebieng
authors.forename: Frieda
authors.initials: F
authors.lastname: Behets
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D000995:Antitubercular Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D015023:Democratic Republic of the Congo; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000379:methods*; D011446:Prospective Studies; D016019:Survival Analysis; D013997:Time Factors; D014376:Tuberculosis / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy*
chemical_list: D044966:Anti-Retroviral Agents; D000995:Antitubercular Agents